non-pharmacological approaches for pain management · 2020-02-05 · • targets...
TRANSCRIPT
February 11, 2020
Drew Sturgeon, PhD
NON-PHARMACOLOGICAL APPROACHES FOR PAIN
MANAGEMENT
DISCLOSURES
• Scientific advisory board member – TribeRx
• No disclosures relevant for current presentation
Non-Pharm Pain Control-Sturgeon-NW GWEC Winter 2020 1
CHRONIC PAIN AND OLDER ADULTS
• By 2050, 20% of US population will be over 65
• Prevalence of chronic pain increases with age
• 15-20% in younger adults
• 30-50% in older adults
• Prevalence in nursing homes may be as high as 80%
• Despite improving survival/longevity, interventions for pain/disability/quality of life have not improved to same degree
Domenichiello & Ramsden 2019, Prog Neuro Psychopharmacol Biol Psychiatry
PAIN ASSESSMENT IN OLDER ADULTS
• Assessment of chronic pain in older adults is inconsistent
• Older patients may not regularly report pain
• Stoicism
• Belief that pain is just “part of aging”
• Cognitive impairment (e.g., dementia)
• Providers may not regularly assess pain levels
• Prioritizing management/assessment of other medical comorbidities
• Different treatment goals for younger vs. older patients (e.g., prioritizing return to work vs. safety)
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CHRONIC PAIN TREATMENT IN PRIMARY CARE
• Primary care providers report barriers to effective pain treatment• Lack of clear treatment guidelines
• Limited training in assessment/treatment of chronic pain
• High perceived difficulty/stressfulness of managing chronic pain
• Need for multidisciplinary approaches in chronic pain in geriatrics• Questionable long-term benefit for
pharmacotherapy as sole intervention
• Limited evidence for chronic opioid therapy in chronic pain and/or older adults
• Patient concerns about safety of medications Wren et al., 2019, Children
NON-PHARMACOLOGICAL TREATMENTS FOR PAIN
• Physiotherapy • Includes specific exercise training but also encouraging patients to increase levels of daily activity
• Small-to-moderate effects on pain and disability, some benefit for QOL, depression, anxiety
• Limited by evidence quality due to low sample sizes, insufficient long-term assessment
• Yoga• Positive (moderate-strong) effects on pain and disability, moderate-quality evidence
• Acupuncture • Shows small effects for pain relief across multiple pain conditions
• TENS • Demonstrates analgesic benefit, but quality of evidence is low
• Spinal manipulation • Good evidence for short-term pain relief and function for CLBP
• Unclear benefit for longer-term outcomes (e.g., return to work)
• Evidence for other CAM treatments is limited
• Psychological/mind-body therapies
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PSYCHOLOGICAL TREATMENT FOR PAIN IN OLDER ADULTS
• Meta-analysis of psychological interventions for pain in older adults (Niknejad et al., 2018, JAMA Internal Medicine)• Pooled analysis of 2608 older adults with chronic pain, 22 studies
• Primarily musculoskeletal pain (others: RA, mixed pain samples)
• Including CBT, MBTs, ACT, self-management interventions
• Small but significant post-treatment effects:
• Pain intensity
• Pain interference & physical function
• Depression & anxiety symptoms
• Self-rated physical health
• Coping variables (self-efficacy, reducing catastrophizing)
• Effects of treatment roughly equivalent to outcomes non-older adults for chronic pain
• Interventions may be enhanced by use of social support, also enhanced by multimodal therapy (e.g., PT or exercise)
PSYCHOLOGY IN PRIMARY CARE
• Psychologists increasingly present in primary care offices (co-located, or in nearby offices)
• Improves:• Clinical outcomes
• Patient/provider satisfaction
• Medication adherence
• May concurrently improve other health outcomes (obesity, smoking, exercise)
• Reduces medical resource use among “high-utilizer” patients
• Model for pain management in primary care
1. PCP addresses specific patient questions about pain (fear of injury, worsening of medical condition), builds patient readiness for self-management (e.g., motivational interviewing)
2. Brief assessment by psychologist to determine suitability of individual therapy vs. more intensive pain treatment
1. May involve brief treatment or educationally-focused groups
3. If indicated (for patients with high disability and/or distress), more regular, intensive follow-up with psychologist
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PAIN TRANSMISSION AND CHRONIFICATION
• Early models (e.g., Melzack & Wall, 1962)• Dorsal horn of spinal cord is a “pain gate,”
modifies nerve signals to brain
• Biological/psychological factors “open” or “close” pain gate
• Ascending and descending signals between brain and body alter experience of pain
• Pain as “threat signal”/“conditioned response”• Chronic pain patterns emerge from brain’s response
to threatening cues
• Input from nerve signals, prior conditioning
• Pain is a protective response, becomes “overused” in chronic pain
• Pain signal can be modified by both biological and psychological factors• Nociception matters, but is only one component of
chronic pain experience
Boorsook, Hargreaves, Bountra, & Porreca, 2014, Science Translational Medicine
CHRONIC PAIN: A COMPLEX SIGNAL
• Experience of pain has 3 components
• Sensory
• Emotional
• Evaluative/cognitive
• All pain has a psychological component
• Acute versus chronic pain
• Distinct patterns of brain activation for acute and chronic pain
• Pain is a “teaching signal” or “protective response”
• Useful in acute pain/injury, harmful in chronic pain
• Effective treatments require “biopsychosocial” approach
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FEAR-AVOIDANCE MODEL OF CHRONIC PAIN
• Vlaeyen & Linton, 2000, 2012
• Model of chronic pain development/maintenance
• Pain produces unhelpful psychological responses
• Catastrophizing
• Fear
• Interpretation of pain as sign of worsening illness/bodily damage
• Negative emotional responses produce avoidant behavior
• Causes deconditioning/sensitization of tissues/CNS
• Reduces function in daily life
• Worsens psychological distress (e.g., depression)
• Combined factors contribute to worsened pain (“vicious cycle”)
MIASKOWSKI 2019 – PAIN PRACTICE
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PSYCHOLOGICAL TREATMENTS IN CHRONIC PAIN
• Multiple approaches to treat psychological factors in chronic pain• Cognitive-behavioral therapy (CBT)
• Pain self-management
• Mindfulness-based stress reduction (MBSR)
• Acceptance and commitment therapy (ACT)
• Graded activity/exposure
• Hypnosis
• Emotional awareness and expression therapy (EAET)
COGNITIVE-BEHAVIORAL THERAPY (CBT) FOR PAIN
• “Gold standard” treatment for chronic pain• Small-to-moderate effects on pain catastrophizing, mood, disability
• Small effect sizes for pain intensity
• Validated in most chronic pain conditions
• Easily adapted to class format
• Useful as a “toolbox” approach to provide skills for pain coping• Behavioral skills (relaxation, activity pacing, communication)
• Behavioral activation (scheduling of pleasurable events)
• Sleep improvement strategies
• Cognitive reappraisal strategies
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Image retrieved from www.psychologytools.org
CBT FOR PAIN MECHANISMS
• Reduced catastrophizing/fear of pain
• Increased active coping (e.g., exercise)
• Reduced avoidant behaviors
• Reduced reliance on short-term coping strategies
• E.g., medications as “first line” coping response
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PAIN SELF-MANAGEMENT
• Typically based on CBT for pain, often incorporates exercise
• Shows small-moderate effects on pain and disability
• Unclear duration of treatment effects
• Efficacy research is limited overall
• Appears better for arthritis than other pain conditions in older adults
• Typically weekly classes, 6-8 weeks
• Can be conducted with non-psychologist facilitator
• May be more cost-effective
• Quality of treatment may be more variable unless manualized approach is adopted
MINDFULNESS-BASED STRESS REDUCTION (MBSR)
• Meditation-based approach to managing pain • Based on Buddhist and yogic
meditation practices
• Pain is an “alarm signal” that leads to unhelpful “automatic” responses
• Emphasizes mindful awareness, non-judgment of bodily sensations, and detached self-observation
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MINDFULNESS-BASED STRESS REDUCTION (MBSR)
• Typical structure – 8-10 weekly classes
• Introduction to mindful meditation/awareness training
• Guided body scan – awareness/acceptance of bodily sensations
• Mindful yoga – approaching limits with gentleness
• Introduction to meditation and stress in everyday life
• Responding to stress/illness in mindful ways
• Mindful communication
• Diet/mindful awareness of intake (of food, substances, emotions)
• Review course content
• Typically requires all-day meditation retreat and daily practice
• Benefits of MBSR
• Decreases unhealthy reactions to pain
• Increases ability to stay in the present
• Interrupt automatic processes (catastrophizing, unhealthy behaviors) that increase pain and distress
• Increases acceptance of pain/psychological flexibility
• Reduces pain catastrophizing
• “Mindful lifestyle” instead of “toolbox”
MINDFULNESS-BASED STRESS REDUCTION (MBSR)
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ACCEPTANCE AND COMMITMENT THERAPY (ACT)
• Focuses on changing responses to thoughts, rather than changing thoughts themselves
• ACT focuses on: • Non-judgment, recognition and acceptance of thoughts
• Increasing the ability to stay focused and in the present
• Acting in ways that are consistent with personal values, not just on immediate relief from pain
• “Meaningful function” instead of “pain relief” as primary goal
• Overlaps with MBSR• Also known as “contextual CBT”
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ACT – TYPICAL SESSIONS
• Introductions and foundations for treatment • Short vs. long-term benefits of treatment/coping • Avoiding pain vs. living well
• Behavior change and mindfulness• Interrelationships between pain, thoughts, emotions, and behaviors
• Values and acceptance• Acceptance of pain• Defining a meaningful life • Identifying problematic values
• Values clarification and goals• Goals versus values • Using values to set meaningful goals
ACT – TYPICAL SESSIONS (2)
• Defusion• Activity pacing/cycling • Discussion of mind’s responses to threat • Distinction between self and thoughts
• Committed Action• Dealing with avoidance/ambivalence• Defusing/separating thoughts from
behavior
• Willingness• Primary vs secondary suffering • Commitment and barriers to action
despite setbacks
• Wrap-up/Conclusions• Preparation for setbacks/relapse
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ACT – RESEARCH SUPPORT
• Emphasizes acceptance of pain and mindfulness• Unlike MBSR, does not require daily meditation
• Meditation is still emphasized, however
• Medium effect sizes for mood, disability, work status, and physical performance• Smaller effects for pain and depression
• Current (smaller) evidence base suggests similar level of efficacy as CBT overall
GRADED EXPOSURE/ACTIVITY FOR PAIN
• Graded activity or in-vivo exposure • Largely physical movement-based
• Decreases perceptions of physical activity as harmful
• Slow, safe, and gradually increasing exposure to movement
• May involve development of fear hierarchy related to pain/activity
• Often conducted by a physical therapist and a psychologist
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GRADED EXPOSURE/ACTIVITY FOR PAIN
• Has shown benefits for:• Reducing pain intensity
• Reducing functional disability
• Reducing pain-related fear and catastrophizing
• Reducing anxiety/depression
• Most studied in LBP• Some evidence for CRPS, whiplash, mixed chronic pain
• Improvements appear to be due to reductions in catastrophizing and perceived harmfulness of activity
HYPNOSIS FOR CHRONIC PAIN
• Uses both traditional aspects of pain psychotherapy (relaxation) and suggestion• Reduce pain intensity
• Reduce pain-related difficulties
• Hypnotic Process• Introduction
• Hypnotic Induction
• Deepening Procedure
• Imagery Suggestions/Metaphors
• Therapeutic Suggestions
• Reducing pain
• Increasing sleep
• Changing location or meaning of pain
• Increasing comfort or ability to ignore pain
• Changing attentional focus away from pain
• Reorienting Procedure
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HYPNOSIS – RESEARCH SUPPORT
• ~70% of patients report pain reduction, either in session or during practice• 20-30% report long-term relief
• Can be added to other treatments• Appears to add incrementally to relief in pain
intensity/frequency/duration
• Always a voluntary process, can be taught as self-hypnosis
EMOTIONAL AWARENESS AND EXPRESSION THERAPY
• Targets unexpressed/repressed emotions and centralized pain
• Prior traumas/adverse life events, styles of emotional expression learned in childhood
• Large comorbidity of chronic pain and PTSD
• Estimated 0-57% of patients with chronic pain have PTSD, higher proportion with centralized pain (e.g., fibromyalgia)
• Negative emotional responses (to pain and other stimuli) and avoidance may reinforce pain circuit
• Therapy targets healthy experiencing and expression of difficult emotions
• Anger, fear, guilt, shame, need, love
• Meditation, expressive writing, and dynamic therapy exercises
• Limitations include small evidence base, no comparative efficacy
• Unclear how to implement in patients with active & untreated psychiatric conditions (e.g., PTSD, major depression)
• Few practitioners trained in this approach
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SUMMARIZING THE LITERATURE
• CBT has strongest research support overall• Useful for high catastrophizing/fear of pain, poor sleep, poor stress coping
• Not ideal for patients with high levels of inflexibility or unwilling to self-manage
• “Why should I cope with this? I want a cure!”
• Graded exposure/activity approaches useful for high fear of pain/perceived harmfulness of activity• PT + Psych may be more beneficial for patients needing intensive treatment
• Hypnosis may enhance outcomes of other interventions
SUMMARIZING THE LITERATURE
• MBSR, ACT - generally comparable outcomes to CBT, but fewer studies• May be better for patients with higher levels of psychological distress or
that are unwilling to self-manage
• Non-directive therapies, unlike CBT
• MBSR and ACT are similar, and differences may be subtle• ACT may be preferable for patients unwilling to do daily meditation or if
they may benefit from re-establishing long-term goals
• MBSR may be preferable for patients who are unwilling to consider “accepting” pain
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SPECIAL CONSIDERATIONS FOR OLDER ADULTS
• Research base is smaller, but still shows benefit of psychological approaches in older adults• May require larger focus on behavioral activation/change, due to skepticism about role of thoughts/emotions
• Emphasize learning new “skills for toolbox” for living with pain
• Clarifying that aging does not equal pain• Even in older adults, pain is due to illness, not aging itself
• Specific focus on addressing fear of falling• Older adults report fear of falling as key factor in reducing activity or exercise
• Emphasis on learning strategies to reduce risk & consequences of falling, still maintaining function and conditioning body
• Chronic pain in dementia• Pain is often (further) underassessed
• Psychosocial treatments may still be effective
• Likely improved with social/cognitive support, implementation into daily routine
CONSIDERATIONS FOR PRIMARY CARE
• Emphasizing self-management (through gradual behavior change) increases likelihood of long-term success• Improving sleep, activity level, mood, diet may facilitate future improvements
• Urge patients to make changes gradually to avoid getting overwhelmed
• Where possible, identifying available mental health resources for patients is key• Specialty psychology services are uncommon, so other methods may include social work or counseling students in
less-populous areas
• Whenever possible, it is valuable to reassure to patients that movement/activity are safe and that their medical conditions are not likely to worsen if they are active• Pain does not always equal damage, especially in chronic pain!
• For more motivated patients, consider recommending a self management-focused book or phone app• Emphasizing role of patient’s own self-management in helping improve their condition
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EDUCATING PATIENTS ABOUT CHRONIC PAIN
• Good pain treatment requires multiple approaches • Medicine, exercise, psychological/mind-body therapy, complementary treatments
• All pain has a psychological component• Seeing a psychologist does not mean pain is not real (or an exclusion
for medical treatment)• Nervous system activity connects “physical” pain to “psychological” pain • If unaddressed, psych symptoms worsen response to medical treatment
• Getting mental health care enhances medical treatment
• Focus is on function and quality of life, despite ongoing pain• “Pain as a lagging indicator”
• Improving sleep, mood, function increases likelihood of pain relief
RESOURCES FOR PRIMARY CARE
• Self-management programs• https://www.cdc.gov/arthritis/interventions/self_manage.htm#CDSMP
• https://www.cdc.gov/arthritis/interventions/physical-activity.html
• https://www.cdc.gov/arthritis/interventions/programs/index.htm
• Mindfulness class finder• https://www.umassmed.edu/cfm/mindfulness-based-programs/mbsr-courses/find-an-mbsr-program/
• https://w3.umassmed.edu/CFMInstructorSearch/#/index/search
• Exercise resources• Silver Sneakers - https://tools.silversneakers.com/
• Sit and Be Fit - https://www.sitandbefit.org/
• Gentle yoga videos searchable on YouTube
• Finding psychological providers for chronic pain• Psychology Today Therapist Search function - https://www.psychologytoday.com/us/therapists
• Searchable by location, insurance, and providers specialized in “chronic pain”
• State psychological associations usually have similar search functions
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PATIENT EDUCATION
• American Chronic Pain Association (www.theacpa.org)
• CBT handouts: https://psychologytools.com/download-therapy-worksheets.html
• Books• Manage Pain Before it Manages You – Caudill
• Pain Survival Guide – Turk & Winter
• Quiet Your Mind and Get to Sleep – Carney & Manber
• The Chronic Pain Solution – Dillard & Hirschman
• Full Catastrophe Living – Kabat-Zinn
• The Feeling Good Handbook – Burns
• Phone apps• Insight Timer – Meditation - free
• Calm, Headspace – Relaxation and meditation – proprietary
• Curable – Biopsychosocial app for chronic pain - proprietary
QUESTIONS?
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